Citation Nr: 9822077
Decision Date: 07/21/98 Archive Date: 08/03/98
DOCKET NO. 96-04 016 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Houston,
Texas
THE ISSUE
Entitlement to service connection for post-traumatic stress
disorder (PTSD).
REPRESENTATION
Appellant represented by: Texas Veterans Commission
ATTORNEY FOR THE BOARD
Michelle L. Nelsen, Associate Counsel
INTRODUCTION
The veteran had active duty from June 1969 to April 1971.
This matter comes before the Board of Veterans’ Appeals
(Board) on appeal from a July 1995 rating decision of the
Department of Veterans Affairs (VA) Regional Office (RO) in
Houston, Texas.
The case returns to the Board following a remand to the RO in
April 1997 for additional development.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends that the RO erred in denying service
connection for PTSD. He essentially contends that he
experienced stressors in service which caused him to suffer
from PTSD. Therefore, a favorable disposition is requested.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1997), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the claimant has not met the
initial burden of submitting evidence sufficient to justify a
belief by a fair and impartial individual that his claim for
entitlement to service connection for PTSD is well grounded.
FINDINGS OF FACT
1. The RO has obtained all relevant evidence necessary for
the equitable disposition of the veteran’s appeal.
2. There is no competent medical evidence of a nexus between
PTSD and his period of active military service or some
incident thereof.
CONCLUSION OF LAW
The veteran’s claim of entitlement to service connection for
PTSD is not well grounded. 38 U.S.C.A. §§ 1110, 5107 (West
1991); 38 C.F.R. §§ 3.102, 3.303(a), 3.304(f) (1997).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Factual Background
The veteran’s service records showed that he served in
Vietnam from May 1970 to April 1971. He was a wheeled
vehicle repairman. Records were negative for any awards or
decorations positively denoting combat. Service medical
records did not reveal any evidence of in-service wounds.
In December 1994, the veteran submitted a claim for service
connection for PTSD. In February 1995, the RO requested from
the veteran information regarding his military service,
details of the claimed in-service stressors, and current
symptoms associated with those stressors. The veteran
responded in an April 1995 statement that he preferred to
discuss his stressors with a VA psychiatrist.
VA medical records showed that the veteran was hospitalized
in February and March 1995. He presented with complaints of
depressed mood, crying spells, greatly increased anxiety,
social isolation, insomnia, hopelessness, suicidal ideation
with no intent, anhedonia, and some weight loss. Mental
status examination was significant for poor eye contact,
anxious and sad affect, and anxious and depressed mood. The
veteran’s motor activity was greatly increased, including an
almost total body tremor and constant fidgeting. There was
no looseness of association or abnormal thought content.
Insight and judgment were fair. The veteran was stabilized
on medications and discharged. The diagnoses included
alcohol dependence; a provisional diagnosis of moderate
single episode major depressive disorder, not psychotic, to
rule out organic mood disorder due to alcohol; and
generalized anxiety disorder. The assigned Global Assessment
of Functioning (GAF) score was 50 currently and 60 in the
last year.
The veteran was afforded a VA psychiatric examination in June
1995. His subjective complaints included sleep disturbance,
dreams of being hurt or hurting someone, hearing voices and
music, excessive worrying, tiredness, difficulty
concentrating, sudden mood changes with crying and angry
spells, feeling that people were watching him, and suicidal
thoughts without intent. The veteran generally avoided
talking about Vietnam. He indicated that in Vietnam he saw
some combat, including firefights, and traveled into the
field to help fix some equipment. He related a long history
of alcohol abuse dating to his discharge from service.
Specifically, the veteran stated that he drank so much during
his last two months in Vietnam that his memory of that time
was a complete blank. The veteran reported being
hospitalized for two weeks for psychiatric treatment in the
mid 1970s. At that time he was depressed with suicidal
thoughts. Mental status examination in June 1995 showed that
the veteran was tense and restless, but alert and
cooperative. His mood was worried and dejected. His affect
was anxious and depressed, but appropriate to expressed
thought content. Speech was normal in rate and amount and
was relevant and goal-directed. The veteran reported recent
ideas of reference without insight. There was no evidence of
hallucinations or delusions. Memory was adequate. The
examiner’s diagnoses were alcohol dependence, recurrent major
depressive disorder in partial remission on medication, and
general anxiety disorder. He assigned a GAF of 50 for the
past year. The examiner also included a provisional
diagnosis of chronic PTSD, commenting that the veteran had
symptoms that met the criteria for a diagnosis of PTSD but
that there was no documentation verifying exposure to combat.
In January 1996, the RO again advised the veteran that
additional evidence regarding the claimed in-service
stressors was required for further action on his claim. The
RO received no response from the veteran.
In April 1997, the Board remanded the case to the RO for
additional development. Specifically, the RO was to again
request from the veteran specific information regarding his
claimed in-service stressors. The RO was also to request
that the veteran provide the names and addresses of any
medical provider from whom he had received psychiatric
treatment since service, specifically any hospitalizations in
the 1970s. The RO was to attempt to verify the veteran’s
claimed stressors with the U.S. Army & Joint Services Support
Group (ESG) (now the U.S. Armed Services Center for Research
of Unit Records (USASCRUR)). Thereafter, the RO was to
schedule the veteran for another VA psychiatric examination.
In a letter dated in May 1997, the RO requested the
information specified in the Board’s remand. The letter
noted the importance of providing the information requested
and indicated that the information should be submitted to VA
by July 15, 1997. The RO received no response from the
veteran.
The case was then forwarded to the Board for final appellate
review.
Analysis
Service connection may be granted if the facts, as shown by
the evidence, demonstrate that the current disability
resulted from an injury or disease incurred in or aggravated
coincident with service in the Armed Forces. 38 U.S.C.A.
§ 1110; 38 C.F.R. § 3.303(a). Service connection for PTSD in
particular requires: 1) medical evidence establishing a clear
diagnosis of the condition; 2) credible supporting evidence
that the claimed inservice stressor actually occurred; and 3)
a link, established by medical evidence, between current
symptomatology and the claimed inservice stressor. 38 C.F.R.
§ 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 140 (1997);
Zarycki v. Brown, 6 Vet. App. 91, 97 (1993). See 61 Fed.
Reg. 52695-52702 (1996) (amending 38 C.F.R. §§ 4.125 and
4.126 to adopt the fourth edition of the American Psychiatric
Association's Diagnostic and Statistical Manual for Mental
Disorders (DSM-IV)).
However, a person claiming VA benefits must meet the initial
burden of submitting evidence “sufficient to justify a
belief in a fair and impartial individual that the claim is
well grounded.” 38 U.S.C.A. § 5107(a); Murphy v. Derwinski,
1 Vet. App. 78, 91 (1990); Gilbert v. Derwinski, 1 Vet. App.
49, 55 (1990). A claim that is well grounded is plausible,
meritorious on its own, or capable of substantiation.
Murphy, 1 Vet. App. at 81; Moreau v. Brown, 9 Vet. App. 389,
393 (1996). For purposes of determining whether a claim is
well grounded, the Board presumes the truthfulness of the
supporting evidence. Robinette v. Brown, 8 Vet. App. 69, 77-
78 (1995); King v. Brown, 5 Vet. App. 19, 21 (1993).
In order for a claim to be well-grounded, there must be
competent evidence of a current disability (a medical
diagnosis); of incurrence or aggravation of a disease or
injury in service (lay or medical evidence); and of a nexus
between the in-service injury or disease and the current
disability (medical evidence). Epps v. Gober, 126 F.3d 1464
(1997); Caluza v. Brown, 7 Vet. App. 498, 504 (1995). Where
the determinative issue involves a medical diagnosis, there
must be competent medical evidence to the effect that the
claim is plausible; lay assertions of medical status do not
constitute competent medical evidence. Grottveit v. Brown,
5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet.
App. 492, 494 (1992).
In this case, the Board finds that the veteran’s claim is not
well grounded. The provisional diagnosis provided by the VA
examiner in June 1995 and the veteran’s statements during the
examination about his claimed stressors are sufficient to
satisfy the first two requirements stated above. However,
there is no competent medical evidence of a nexus between the
PTSD and the veteran’s period of active military service.
The examiner specifically stated in the examination report
that there was no verification of the veteran’s combat
exposure. No other service-related stressors were discussed
by the veteran or the examiner. Thus, there is no medical
evidence of a nexus between the PTSD and service. The
veteran is not a medical or mental health professional. His
statements and opinions regarding an etiological relationship
between his psychiatric disorders and service is not
competent medical evidence required of a well grounded claim.
Grottveit, 5 Vet. App. at 93; Espiritu, 2 Vet. App. at 494.
With respect to the instructions in the April 1997 remand to
the RO, the Board makes the following comments. First,
although the RO was instructed to attempt to verify the
claimed in-service stressors, the information provided by the
veteran was insufficient even to support making such an
attempt. The only stressor information of record was related
during the June 1995 VA examination when the veteran
indicated that he saw some combat, including firefights, and
traveled into the field to help fix some equipment. He has
not provided any descriptions of specific traumatic
incidents, dates of occurrence, unit designations during such
traumatic events, names of casualties, or other information
vitally necessary to the process of searching military
records for verifying evidence. The veteran did not respond
to any of the letters from the RO requesting this
information. The claims folder does not contain any letters
returned for incorrect address or other indication that the
veteran did not receive these letters. Given these
circumstances, the RO was not obliged to send the meager
information available to ESG. Second, the RO was not
required to schedule the veteran for another VA psychiatric
examination because there are no verified or verifiable
stressors on which to base a diagnosis of PTSD.
In conclusion, the Board finds that the veteran has not
submitted a well grounded claim of entitlement to service
connection for PTSD. 38 U.S.C.A. § 5107(a). Thus, the duty
to assist is not triggered and VA has no obligation to
further develop the veteran’s claim. See Epps, 126 F.3d at
1469; Grivois v. Brown, 5 Vet. App. 136, 140 (1994).
The Board recognizes that this appeal is being disposed of in
a manner that differs from that used by the RO. The RO
denied the veteran’s claim on the merits, while the Board has
concluded that the claim is not well grounded. However, the
Court has held that “when an RO does not specifically
address the question whether a claim is well grounded but
rather, as here, proceeds to adjudication on the merits,
there is no prejudice to the veteran solely from the omission
of the well-grounded analysis.” Meyer v. Brown, 9 Vet. App.
425, 432 (1996).
If the veteran wishes to complete his application for service
connection for PTSD, he must submit information regarding the
claimed in-service stressors which is sufficiently detailed
to permit verification of those claims. In addition, there
must be competent medical evidence linking a diagnosis of
PTSD to the claimed stressors. Robinette, 8 Vet. App. at 77-
78.
ORDER
Entitlement to service connection for PTSD is denied.
JAMES W. LOEB
Acting Member, Board of Veterans' Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1997), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
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